P5015 - Iatrogenic Ileal Perforation: A Case of Migrating Pacing Wires

Sarah Mann, MD, Kevin McGrath, MD
University of Pittsburgh Medical Center, Pittsburgh, PA

Introduction: Post-operative abdominal pain and ileus are common complaints, often attributed to benign causes. However, in certain cases, these symptoms can herald more serious underlying pathology. Here we present a unique case of postoperative persistent abdominal discomfort and ileus revealing an unexpected complication – perforation of the bowel.

Case Description/Methods: A 73-year-old man with history of anxiety presented to the hospital complaining of tearing chest pain. CTA chest revealed a hyperacute type A aortic dissection with malperfusion. He underwent a total arch replacement, aortic root reconstruction and repair, and aortic valve resuspension with placement of two atrial and ventricular pacing wires.

Post-operatively the patient developed colonic distension. On post-operative day 4, an abdominal x-ray demonstrated new marked gaseous dilation of the cecum to 16.4 cm and mild small bowel dilation concerning for acute colonic pseudo-obstruction. A rectal tube was placed for decompression. Repeat abdominal x-ray showed persistent cecal dilation and the patient was started on Pyridostigmine and a SMOG enema was administered. On post-operative day 7, a CT abdomen/pelvis revealed small to moderate pneumoperitoneum and persistent mild diffuse gaseous distention of small bowel loops and right colon. Ex-lap showed a pacer wire had punctured through a distal ileal loop in addition to a 9 cm serosal tear of the cecum. The pacer wires were removed, both ileum and cecum were repaired, and the skin was left open and packed wet to dry with placement of a wound vac for healing. The patient was discharged eight days later.

Discussion: This case highlights the challenge in identifying a rare complication of cardiac pacing leads. The patient was first diagnosed with post-operative ileus. However, after imaging revealed cecal dilation, a diagnosis of acute colonic pseudo-obstruction was made. Ultimately given persistent pain with imaging revealing pneumoperitoneum, the patient was taken to the OR and found to have perforated bowel. Epicardial pacing leads are often placed during cardiac surgeries for diagnostic and therapeutic intervention. The leads are passed through the mediastinum, subcutaneous tissue and protrude through the skin. Migration of epicardial pacing leads is a rare complication but associated with diarrhea, intestinal obstruction, and nerve stimulation of the surrounding structures. This case underscores the importance of close post-operative monitoring and consideration of uncommon complications.


Disclosures:


Sarah Mann, MD, Kevin McGrath, MD. P5015 - Iatrogenic Ileal Perforation: A Case of Migrating Pacing Wires, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.